SGH Questionnaire

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Personal Details

Name(Required)

Gender(Required)

D.O.B.(Required)

Height(Required)

Weight(Required)

Occupation(Required)

Contact Details

Email address(Required)

Phone Number(Required)

Address(Required)

Consultation

What are your current main complaints, symptoms or goals? Please list these in order of priority to you(Required)

If you were to resolve your complaints or symptoms how would that make you feel and what would that change?(Required)

What have you done in the past that has helped?(Required)

What have you tried in the past that has not helped?(Required)

When was the last time you felt well?(Required)

Please provide details on any significant medical history. If possible, please list these in date order, adding your date or age where possible and any additional notes you may have(Required)

Please list any medications your are currently taking, their dosage and what you are taking them for(Required)

Please list any supplements you are currently taking, their dosage and what you are taking them for(Required)

Do you have any allergies? If yes, please list any allergies that you have(Required)

Please provide details on any significant life events. If possible, please list these in date order, adding your date or age where possible and any additional notes you may have(Required)

Please list any family medical history, focusing predominantly on close family relatives(Required)

Are you currently undergoing any additional therapies or seeing other health professionals to help with your goals?(Required)

Nutrition & Lifestyle

Prior to the initial consultation please complete a minimum of 3 days or up to 7-day food diary. You can download a template for this by clicking here. Once complete you can bring it with you on the day to the consultation or email it back to use prior to the consultation via admin@stevegranthealth.com.

Do you have any food intolerances, sensitivities or allergies? If so, please list them(Required)

Do you have any foods you avoid for religious reasons? If so, please list them(Required)

Do you have any other dietary restrictions? If so, please list them(Required)

Do you drink alcohol? If so, how much do you drink on average per week?(Required)

Do you smoke cigarettes? If so, on average how many on average do you smoke per day?(Required)

Do you exercise? If so please tell us how much and what type of exercise you do?(Required)

What exercise or movement activities do you most enjoy doing?(Required)

What is your average duration of sleep per night?(Required)

What is your sleep quality like?(Required)

Do you have consistent sleeping hours, as in what time you go to sleep and what time you wake up?(Required)

Do you travel across time zones frequently with work or have a job that involves night and day shift work?(Required)

What are your main sources of stress? please list in order of significance(Required)

What makes you happy?(Required)

Creating Change

For the following 7 questions, please rate on a scale from 1 = not willing to 5 = very willing.

In order to improve your health, how willing are you to modify your nutritional habits?(Required)

In order to improve your health, how willing are you to modify your work demands?(Required)

In order to improve your health, how willing are you to modify evening routine & sleep habits?(Required)

In order to improve your health, how willing are you to engage in appropriate movement?(Required)

In order to improve your health, how willing are you to track your nutrition and lifestyle habits each day?(Required)

In order to improve your health, how willing are you to have periodic lab tests to guide decisions and assess progress?(Required)

In order to improve your health, how willing are you to take nutritional supplements when appropriate?(Required)

What do you feel you need to help you follow through with any nutrition and lifestyle changes given?(Required)

Do you have any comments about challenges that you have faced in the past of that you are concerned about when it comes to adapting your nutrition and lifestyle?(Required)

Further Information

If you have any recent and potentially relevant laboratory test results or consultation reports you would like to share prior to the consultation, either upload them below, or email these to Fay on admin@stevegranthealth.com and she will forward these onto your practitioner prior to your session. Upload relevant laboratory test results or consultation reports (if necessary)

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Health Assessment Questionnaire for Nutrition & Functional Medicine